IPP: Skin

Question 1

What is atopic eczema?

Answer 1

Atopic Eczema is a chronic, itchy, inflammatory skin condition that affects people of all ages, although most frequent in childhood

Typically episodic disease of flares and remissions. In severe cases can be continuous.

Question 2

What factors are thought to contribute to the development of eczema?

Answer 2

Genetic predisposition, skin barrier dysfunction, environmental factors (pets, pollen) and immune system dysfunction are thought to play a role in its development.

Question 3

What are the complications of eczema?

Answer 3

infection, such as bacterial infection with Staphylococcus aureus, herpes simplex virus infection (may be widespread if eczema herpeticum), or superficial fungal infection.

Psychosocial issues, such as missing school, depression, disturbed sleep, and reduced self-confidence.

Question 4

Describe diagnosis and assessment of eczema

Answer 4

clinical. Investigations are not routinely required but may be useful in excluding differential diagnoses.

At each consultation, the severity of the eczema and the psychological impact should be assessed (Impact on school/work, social life, sleep and mood):

• Clear - if there is normal skin and no evidence of active eczema.
• Mild - if there are areas of dry skin, and infrequent itching (with or without small areas of redness)
• Moderate - if there are areas of dry skin, frequent itching, and redness (with or without excoriation and localized skin thickening)
• Severe - if there are widespread areas of dry skin, incessant itching, and redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking, and alteration of pigmentation).
• Infected - if eczema is weeping, crusted, or there are pustules, with fever or malaise

Psychological Impact

• None - no impact on quality of life.
• Mild - little impact on everyday activities, sleep, and psychosocial well-being.
• Moderate - moderate impact on everyday activities and psychosocial well-being, and frequently disturbed sleep.
• Severe - severe limitation of everyday activities and psychosocial functioning, and loss of sleep every night.

Question 5

What is management of Eczema?

Answer 5

ANAGEMENT

Stepped approach recommended:

Emollients are the first-line treatments during both acute flares and remissions of the condition:

• frequent and liberal use
• 3-4 hourly is normal

The use of topical steroids should be considered for red, inflamed skin. The lowest potency and amount of topical corticosteroid necessary to control symptoms should be prescribed, depending on the severity of the flare:

• Use once a day for 7-14 days
• If not improved in 2 weeks return

If there is persistent, severe itch, or urticaria, a one-month trial of a non-sedating antihistamine should be considered.

• such as cetirizine, loratadine, or fexofenadine

If itching is severe and affecting sleep, a short course of a sedating antihistamine should be considered (if appropriate).

• (such as chlorphenamine).

If there is severe, extensive eczema, a short course of oral corticosteroids should be considered.

• 30 mg prednisolone taken in the morning for 1 week should be sufficient.

If eczema is weeping, crusted, or there are pustules, with fever or malaise, secondary bacterial infection should be considered, and antibiotic treatment should be prescribed.

• Flucloxacillin is the first-line choice.
• erythromycin if the person has an allergy to penicillin/resistance or intolerateblae
• If there are localized areas of infection, consider prescribing a topical antibiotic.
• Advise that topical antibiotics should be used for no longer than 2 weeks.

Question 6

Treatment of mild, moderate and severe eczema in more depth

Answer 6

MILD

Prescribe generous amounts of emollients, and advise frequent and liberal use.

Consider prescribing a mild topical corticosteroid (such as hydrocortisone 1% (available OTC)) for areas of red skin. Treatment should be continued for 48 hours after the flare has been controlled.

MODERATE

Consider possibility of triggers or infection which can precipitate or worsen a flare.

Prescribe a generous amount of emollients, and advise frequent and liberal use (more than usual).

If the skin is inflamed, prescribe a moderately potent topical corticosteroid (for example betamethasone valerate 0.025% or clobetasone butyrate 0.05%) to be used on inflamed areas.

For delicate areas of skin (such as the face and flexures), consider starting with a mild potency topical corticosteroid (such as hydrocortisone 1%) and increase to a moderate potency corticosteroid only if necessary. Aim for a maximum of 5 days’ use.

If there is severe itch or urticaria, consider prescribing a one-month trial of a non-sedating antihistamine (such as cetirizine, loratadine, or fexofenadine)

SEVERE

Prescribe a generous amount of emollients and advise frequent and liberal use (more than usual).

If the skin is inflamed, prescribe a potent topical corticosteroid (for example betamethasone valerate 0.1%) to be used on inflamed areas.

For delicate areas of skin such as the face and flexures, use a moderate potency corticosteroid (such as betamethasone valerate 0.025% or clobetasone butyrate 0.05%). Aim for a maximum of 5 days’ use.

If there is severe itch or urticaria, consider prescribing a one-month trial of a non-sedating antihistamine

If itching is severe and affecting sleep, consider prescribing a short course (maximum or two weeks) of a sedating antihistamine

If there is severe, extensive eczema causing psychological distress, consider prescribing a short course of an oral corticosteroid (refer children under 16 years of age).

INFECTED

Prescribe appropriate treatment.

If there are extensive areas of infected eczema, swab the skin and prescribe an oral antibiotic. Routine swabbing of skin that is not infected is not recommended.

Question 7

Counselling on use of emollients

Answer 7

• Emollient usage – liberally and frequent application, even when skin is clear or improved (2-3hr is normal).
• Use all the time and at least twice a day even when you are not experiencing symptoms
• Do not rub it in – smooth it into the skin in the same direction as the hair grows.
• Use emollient after a bath or shower, gently pat the skin dry and apply the emollient while the skin is moist to keep moisture in
• If your emollient is not in a pump dispenser then use a clean spoon or spatula to remove the emollient to reduce the risk of infection
• Wait ~15-30 min after applying emollient before applying CCS
• Emollients – if skin reaction occurs stop and use another one

Question 8

Lifestyle advice for eczema

Answer 8

• Lifestyle advice:
• Determine and avoid triggers – soaps, certain clothing, animals and heat (keep room cool)
• Avoid scratching and instead rub area with fingers to alleviate itch
  
  • Keep nails short and clean
  • Skin covered in light clothing
  • Anti-scratch mitts
• Avoiding using soap and detergents
• Dietary changes:
  
  • E.g. some foods such as eggs and cow’s milk can trigger symptoms
  • Speak to GP before making significant changes (particularly important for children and breast-feeding mums)

Question 9

ADVERSE EFFECTS TOPICAL CCS

Answer 9

• Transient burning or stinging — this is common, especially in the first 2 days of application on untreated, inflamed skin. It does not usually require a change of treatment, as it improves as the skin responds to treatment.
• Worsening and spreading of untreated infection.
• Thinning of the skin — the skin improves after stopping treatment.
• Permanent striae.
• Allergic contact dermatitis — due to the corticosteroid or the excipients.
• Acne vulgaris (or worsening of existing acne) or acne rosacea.
• Mild depigmentation — usually reversible.
• Excessive hair growth at the site of application (hypertrichosis)

Question 10

What is contact dermatitis?

What can be used to determine the cause?

What are some causes?

Answer 10

Contact dermatitis is an inflammatory skin condition which occurs as a result of exposure to an external irritant or allergen e.g. cosmetics, hair dye, metals (nickel), topical medication (AB, CCS), certain plants.

The patch test can be used to identify cause of contact dermatitis.

Question 11

Differential diagnosis of dermatitis?

Answer 11

Differential diagnosis: skin infection (cellulitis, impetigo, fungal infections), and other skin conditions such as urticaria, psoriasis, and lupus erythematosus.

Question 12

Management of dermatitis

Answer 12

• Avoiding contact with the stimulus.
  
  • If not possible – use gloves or rinse area with soap/soap substitute as soon as possible after contact.
• Liberal application of an emollient.
• Consideration of topical corticosteroids

Question 13

What is psoriasis?

Where does it commonly occur?

Answer 13

Psoriasis is a chronic inflammatory condition that causes red, flaky, crusty patches of skin covered with silvery scales. These patches can be itchy or sore.

Normally the condition follows a relapsing-remitting pattern where it can have periods with less or no symptoms and then periods of flare-up.

Most commonly develops in adults under 35 but can occur in all ages and is genetically inherited.

Patches normally appear on the elbows, knees, scalp and lower back – can be anywhere.

Although psoriasis is treated under specialist care it is important for pharmacists to be aware of the conditions

Question 14

What is typical psoriasis treatment

Answer 14

TREATMENT

Topical Treatment:

• Potent CCS and Vitamin D (or analogue) both applied once daily at separate times (one morning and other evening) up to 4 weeks if trunk of limb psoriasis.
  
  • Potent CCS max use 8 weeks and Very potent CCS max 4 weeks
  • Aim for 4 week break between courses
  • Potent CCS not used in children/ young people
  • RISKS
• Scalp psoriasis:
  
  • Potent CCS applied once daily for up to 4 weeks

Question 16

What is Acne?

Answer 16

Acne vulgaris is a chronic inflammatory condition affecting mainly the face, back and chest- it is characterized by blockage and inflammation of the pilosebaceous unit (the hair follicle, hair shaft and sebaceous gland). It presents with lesions which can be non-inflammatory (comedones), inflammatory (papules, pustules and nodules) or a mixture of both.

Question 17

What is life-stylea advice and counselling for acnce

Answer 17

• To avoid over cleaning the skin (which may cause dryness and irritation) — acne is not caused by poor hygiene.
• To use non-comedogenic make-up, cleansers and/or emollients with a pH close to the skin if needed.
• To avoid picking and squeezing spots which may increase the risk of scarring.
• That acne treatments are effective but take time to work — usually up to 8 weeks.
• That acne treatments may irritate the skin, especially at the start of treatment — concentration or application frequency may need to be reduced if skin irritation occurs.

Question 18

What is the management for acnce?

Answer 18

Mild: where open and closed comedones (blackheads and whiteheads) predominate

• Single topical treatment such as a topical retinoid (e.g. adapalene if not CI (POM)) or benzoyl peroxide (OTC) should be considered for first line treatment
  
  • If both CI or poorly tolerated, azelaic acid can be considered.

Moderate: where inflammatory lesions (paules and pustules) predominate and response to topical preparation alone is inadequate:

• Oral AB such as lymecycline or doxycycline (for max 3 months)
  
  • A topical retinoid or benzoyl peroxide should always be co-prescribed to prevent AB resistance
  • Macrolide antibiotics (such as erythromycin) should generally be avoided due to high levels of P. acnes resistance but can be used if tetracycline’s are contraindicated (for example in pregnancy).
• Non-response to two different courses of antibiotics, or scarring are indications for referral to dermatology for consideration of treatment with isotretinoin.
• Combined oral contraceptives can be considered in combo with topical agent as alternative to systemic AB.

If these treatments are in adequate refer to dermatologist:

• isotretinoin (strong retiniod)

Question 19

What dose and frequency should benzyol peroxide be prescribed?

What are potential side effects?

What should be done if used in combo with other topical agent

Answer 19

Benzyl Peroxide:

• Apply to the skin 1–2 times a day, preferably after washing with soap and water, and start treatment with lower-strength preparations.
• Avoid contact with broken skin, eyes, mouth.
• Side effects:
  
  • Skin irritation (dryness, peeling) – reduce frequency or stop until settles then re-introduce at lower concentration or frequency.
    
    • Swelling of eyes/itching – allergic
  • Increase sun burn risk – avoid exposure or protective clothing
  • May bleach fabrics and hair
• If use in combo with topical AB or topical retinoid apply 12hr apart – one at night and one in morning

Question 20

What topical retinoids are available?

Dose and frequency?

CI?

Side effects?

Answer 20

• Adapalene and tretinoin used in >12s & Isotretinoin only in adults
• Application usually once or twice a day – apply sparingly over the whole affected area not just visible spots
• Mosituriser as can have drying effect
• Contraindicated in:
  
  • Hypersensitvity
  • Pregn/ breastfeeding – if child bearing age need effective contraception
  • Severe acnce
  • Avoid sun exposure and application on eyes, mouth etc.
• Side effects:
  
  • Skin irritation
  • Increased UV sensitivity

See Benzoyl peroxide for use in combination

Question 22

What are the different types of acnce?

Answer 22

Inflammation: Benzoyl peroxide

Black heads: unplugging – retinoid.

Both: Combination of both topical agents

Question 24

What is head-lice and who is typically affected?

Answer 24

Head Lice affect all ages but are more common in children aged 4-11 years.

Parasitic inscets that infest the hair and feed on blood from the scalp – a head lice infestation is called pediculosis capitis.

Question 25

How head lice confirmed?

Answer 25

Combing wet or dry hair using fine-tooth comb allows detection. Only active if live head lice found – should only be treated if active & all family members should be treated on same day.

• Itchy scalp and eggs is not proof of live infestation

Question 26

What is management options for head lice?

What should you do if reinfestation occurs and how is this determined?

Answer 26

head lice can be treated with one of the following:

• A physical insecticide, such as dimeticone 4% lotion (Hedrin®).
• A traditional insecticide, such as malathion 0.5% aqueous liquid (Derbac-M®).
• Wet combing with a fine-toothed head louse comb (such as the Bug Buster® comb).

Detection combing should be carried out after treatment to determine success. Repeat treatment or try other if unsuccessful.

Question 27

What advice should you give to parents relating to head lice

Answer 27

Children who are being treated for head lice can still attend school.

There is no evidence that head lice have a preference for either clean or dirty hair.

There is no need to treat (wash at high temperature or fumigate) clothing or bedding that has been in contact with lice, as the lifespan of a head louse is very short (1 –2 days) once it is detached from a human head.

Essential oil-based treatments and herbal treatments are not recommended due to the lack of good-quality evidence on their safety and efficacy.

It is not possible to prevent head lice infestation. Children of primary school age should be examined regularly at home (using a detection comb) to identify infestation early

Question 28

What is imeptigo?

Who typically is affected?

Answer 28

Impetigo is a skin infection that’s very contagious but not usually serious. It often gets better in 7 to 10 days if you get treatment. Anyone can get it, but it’s very common in young children.

There are 2 main forms: non-bullous impetigo (sores) and bullous impetigo (blisters).

Question 29

What are the symptoms of impetigo?

Answer 29

Impetigo starts with red sores or blisters. They quickly burst and leave crusty, golden-brown patches. These can:

• look a bit like cornflakes stuck to your skin
• get bigger
• spread to other parts of your body
• be itchy
• sometimes be painful

Question 30

What does diagnosis of impetigo involve?

Answer 30

Diagnosis usually clinical but swabs for culture sensitivities can be considered in cases which are treatment-resistance, reccurent or widespread.

Question 31

What is management of impetigo in primary care?

Answer 31

MANAGEMENT

Advising the person on hygiene measures to aid healing and stop infection spreading to other areas of the body and to other people.

Treating localized non-bullous infection with topical hydrogen peroxide for five days, or a topical antibiotic if this is not suitable. More extensive, severe or bullous infection may require oral antibiotics (flucloxacillin or clarithromycin if allergic to penicillin) for five days (or seven days depending on clinical judgment).

Follow up is not usually necessary but the person should be advised to return if symptoms worsen rapidly or significantly at any time, or have not improved after completing a course of treatment.

Question 32

In the pharmacy what can we supply for impetigo?

What is the dosage regime?

Answer 32

2% Fusidic acid topical (15g).

Apply to lesion 4 times a day for 5 days – max 5 days and max 1 supply in 3 months.

Question 33

What is the inlcusion and exlcusion criteria for fusidic acid?

What is this supplied under?

Answer 33

Pharmacy First

Inclusion criteria:

• ≥ 2 years old with minor skin infection limited to few lesions in one area of the body
• The rash consists of vesicles that weep and then dry to form yellow-brown crusts
• Informed consent by parent/carer
• Patient must be present at consultation

Exclusion:

• Under 2 years
• Multiple sites of skin infection
• History of MRSA colonisation/infection
• Allergy to excipients
• Underlying skin condition on site of impetigo infection

Question 34

What counselling points should be mentioned when supplying fusidic acid?

Answer 34

Counselling:

• Wash hands before and after application
• Where possible remove scaps by bathing in warm water before applying cream
• Inform school of condition
• Do not apply to breast if patient is breastfeeding
• Inform possible side effects

Question 35

What is lifestyle advice for impetigo?

Answer 35

• stay away from school or work
  
  • until the lesions are dry and scabbed over or 48 hours after antibiotic treatment has started.
• keep sores, blisters and crusty patches clean and dry
• cover them with loose clothing or gauze bandages
• wash your hands frequently
• wash your flannels, sheets and towels at a high temperature
• wash or wipe down toys with detergent and warm water if your children have impetigo
• do not touch or scratch sores, blisters or crusty patches – this also helps stop scarring
• do not have close contact with children or people with diabetes or a weakened immune system (if they’re having chemotherapy, for example)
• do not share flannels, sheets or towels
• do not prepare food for other people
• do not go to the gym
• do not play contact sports like football
• Ensuring pre-existing skin conditions (such as eczema) are optimally treated.

Question 36

What is nappy rash?

Answer 36

Nappy Rash is a dermatitis that is confined to the area covered by the nappy. It appears as redness although secondary infection may cause weeping of the rash.

Skin barrier function compromised by skin maceration, friction, prolonged skin contact with urine and faces and resultant increased skin pH.

Question 37

Risk factors for nappy rash

Answer 37

Skin cleaning regime, type of nappy, use of baby wipes and other topical preparations and recent diarrhoea or AB use

Question 38

What does diagnosis of nappy rash include?

Answer 38

Clinical Features:

• Child is distressed, agitated, or uncomfortable, as the rash may be itchy and painful.
• Well-defined areas of confluent erythema (continuous redness) and scattered papules over convex surfaces in contact with the nappy (the buttocks, genitalia, suprapubic area, and upper thighs), with sparing of the inguinal skin creases and gluteal cleft.
• There may be skin erosions, oedema, and ulceration if there is severe involvement.

Question 39

What does assessment of nappy rash include

Answer 39

Assessment of a child with suspected nappy rash should include:

• Asking about the location, nature, and duration of rash; any previous episodes; and any treatments, such as barrier preparations.
• Examining for oral candidiasis and features which may suggest candidal or bacterial secondary infection, especially if the rash is severe.
• Considering taking a skin swab for culture and sensitivity, if secondary bacterial infection is suspected.

Question 40

What does management of nappy rash involve - both lifestyle and medicine

Answer 40

Advising the parents/carers on self-management strategies:

• using a nappy with high absorbency
  
  • Ensure fits properly
• leaving nappies off for as long as possible
• Changing the nappy frequently (3-4 hourly) and as soon as possible after wetting or soiling
• using water, or fragrance- and alcohol-free baby wipes
• drying gently after cleaning
• avoiding potential irritants such as soaps and bubble bath.
• Bathe daily – avoid more than 2x a day as can dry skin
• Do not use talcum powder as it contains ingredients which could irritate skin
• Advising on sources of written information and support.
• Use of a barrier preparation to protect the skin, if there is mild erythema and the child is asymptomatic.
  
  • E.g. Zinx and caster oil ointment and white soft paraffin BP ointment
  • Apply thinly at each nappy change
• Prescribing topical hydrocortisone 1% cream once a day in addition, if the rash appears inflamed and is causing discomfort.
  
  • Apply once daily until symptoms clear or for maximum of 7 days
  • Apply then wait few mins before barrier preparation
• Prescribing a topical imidazole cream, if the rash persists and candida infection is suspected or confirmed on swab.
• Oral antibiotics, if the rash persists and bacterial infection is suspected or confirmed on swab.
• Arranging to review the child, the time interval depending on clinical judgement, to assess the response to treatment:

Question 41

What is scabies?

Answer 41

Scabies is a skin infection caused by the mite Sarcoptes scabiei which is extremely itchy and is accompanied by a rash of small red papules.

Prevalence greatest in 10-19 year olds and more common in women and in winter months. Spreads via direct contact with the skin

Question 42

Diagnosis of scabies

Answer 42

DIAGNOSIS

The diagnosis of scabies is usually made from the history and examination of the affected individual, as well as from the history of the family and close contacts. Microscopy of skin scrapings can be used to confirm the diagnosis.

If crusted scabies is suspected, the possibility of underlying immunodeficiency should be considered.

Question 43

Management of scabies?

Answer 43

Scabies is curable if treated; however, if not treated it may persist indefinitely.

Treating the affected person and all household members, close contacts, and sexual contacts with a topical insecticide (e.g. permethrin 5% cream or malathion 0.5% liquid), even in the absence of symptoms.

• Apply to whole body from chin and ears downwards – special attention to areas between fingers, toes and under nails. If immunosuppressed or very young or old apply to face and scalp too.
• Apply to cool dry skin and allow to dry before dressing
• Permethrin washed off after 8-12hr and malathion after 24hr. Body areas that are washed within 8 hours of permethrin application or 24 hours of malathion application should be treated again.
• Mittens can be used to prevent infants putting treated hands in mouth
• A second application is required one week after first.
• Permethrin (first-line):
  
  • >12: 1 to 2 (30g) tubes
  • 6-12 years: up to ½ a tube (15g)
  • 1-5 years: ¼ tube (7.5g)
  • 2m-1Y: 1/8 tube: (3.75g)

Malathion:

• Apply a thin film to the skin surface.

Giving detailed advice on how the insecticide should be applied.

Considering symptomatic treatment for itching (e.g. topical crotamiton).

Treating any associated conditions (e.g. infection).

If symptoms not cleared within 2-4 weeks from initial application – follow up and review.

Their bedding, clothing, and towels (and those of all potentially infested contacts) should be decontaminated by washing at a high temperature (at least 60°C) and drying in a hot dryer, or dry-cleaning, or by sealing in a plastic bag for at least 72 hours.

Question 44

What are cold sores and what are they caused by?

How is this transmitted?

Answer 44

Cold sores caused by herpes simplex type 1 and type 2 is associated with genital herpes. The virus remains dormant in the sensory nerve ganglia following primary infection during childhood and is re-activated by a number of trigger factors.

It causes a mild, self-limiting infection of the lips, cheeks, or nose or oropharyngeal mucosa.

Most HSV-1 is asymptomatic.

HSV-1 is usually transmitted via direct contact with infected secretions entering via the skin or mucous membranes, from a person who is actively shedding the virus.

Question 45

Diagnosis and symptoms of Herpes

Answer 45

DIAGNOSIS/ SYMPTOMS

Primary herpes labialis lesions usually resolve within 10–14 days; gingivostomatitis usually heals within 2–3 weeks.

The diagnosis of oral herpes simplex is based on the person’s age and clinical features, such as the history, location, and appearance of lesions:

• Herpes labialis may present with a prodrome of fever, sore throat, and lymphadenopathy, particularly in primary infections.
• Initial symptoms of pain, burning, tingling, and itching may precede visible lesions and typically last 6–48 hours.
• Herpes labialis lesions are typically crops of vesicles that rupture, ulcer, crust, and heal (usually without scarring).
• Herpes gingivostomatitis lesions are typically crops of painful vesicles that rupture and form ulcers on the pharyngeal and oral mucosa.
• People who are immunocompromised may have severe, atypical lesions anywhere in the oral cavity.

Assessment of a person with suspected oral herpes simplex should include:

• Any known trigger factors, such as ultraviolet light, stress, fever, menstruation, illness or trauma to the area.
• Any red flags for oral cancer.

Question 46

Management of cold sores

Answer 46

• PHARMACY FIRST ACIVLOVIR AND OTC MEDS
• Offering analgesia to treat pain and fever, if needed.
• Considering prescribing an episodic oral antiviral such as aciclovir or valaciclovir, for healthy people with a primary or recurrent infection if lesions are frequent, persistent, or severe; people with recurrent gingivostomatitis; and people who are immunocompromised with primary or recurrent infection, depending on clinical judgement.
  
  • Indicated within 5 days of start of new episode
  • Aciclovir:
    
    • ≥ 2Y: 400mg 3x a day for 5 day
    • 1M to <2Y: 100mg 5x a day for 5 days
    • Immunocompromised – double dose for healthy
  • Valaciclovir:
    
    • Adults and children aged 12 years and over — prescribe 500 mg twice a day for 5 days for primary infections, which may be extended to 10 days if new lesions appear during treatment, or if healing is incomplete. Prescribe 500 mg twice a day for 3–5 days for recurrent episodes. An alternative regime for herpes labialis is 2000 mg twice a day for one day only. The second dose should be taken about 12 hours after the first dose.
    • Immunocompromised people — prescribe 1000 mg twice a day for up to 10 days for primary infections, and for 5–10 days for recurrent episodes.
• Advising that topical antiviral preparations, topical analgesics, mouthwash and lip barrier preparations are not routinely recommended, but some people may find them helpful, and they are available over-the-counter.
• Offering self-care advice to avoid trigger factors, if possible, and to reduce the risk of autoinoculation and transmission to other people.
• The use of sunscreen or sunblock lip balm for people with recurrent infections triggered by sunlight

Question 47

What are warts and what are they caused by and how are they spread?

Answer 47

Warts and Verrucae are caused by the human papilloma virus (HPV) and frequently affect the hands, feet and anogenital area. Verrucas are found on the soles of the foot particularly in weight bearing areas as the outward growth of the wart is prevented and the wart grows inwards.

Incidence is thought to increase during school years reaching a peak in adolescence and early adulthood before declining in later adulthood.

Warts are usually spread by direct skin-to-skin contact, or indirectly via contact with contaminated floors or surfaces (for example in swimming pools or communal washing areas).

Question 48

What is management for warts

Answer 48

MANAGEMENT

Although warts can be cosmetically unsightly, they are not harmful; usually they do not cause symptoms and resolve without treatment.

Warts are contagious, but the risk of transmission is thought to be low.To reduce the risk of transmission:

• Cover the wart with a waterproof plaster when swimming this is sufficient compared to swimming sock.
• Wear flip-flops or other appropriate footwear in communal showers.
• Avoid sharing shoes, socks, or towels.

In order to limit personal spread (auto-inoculation):

• Avoid scratching lesions.
• Avoid biting nails or sucking fingers that have warts.
• Keep feet dry and change socks daily.
• Children with warts or verrucae should not be excluded from activities, such as sports and swimming, but should take care to minimize transmission.

Medicine:

• Medicine not often required – resolve spontaneously normally
• Treatment may be prolonged and can have adverse effects.
• Cryotherapy requires several treatments, can be painful at the time of application, and may cause pain, blistering, infection, scarring, and depigmentation.
• Topical salicylic acid may require administration for up to 12 weeks and can cause local skin irritation.
• OTC: Wartner Wart and Verruca Remover, Endwarts Freeze, Endwarts Pen

Question 49

What is athletes foot?

Answer 49

Athlete’s foot is a common fungal infection that affects the feet. It can usually be treated with creams, sprays or powders from a pharmacy, but it can keep coming back

Common in children but rare in pre-pubertal children

Question 50

Risk factors for athletes foot

Answer 50

Risk factors for acquiring infection include hot, humid climates or working environments; occlusive footwear; hyperhidrosis; walking on contaminated surfaces; and immunocompromised states.

Question 51

DIAGNOSIS/ ASSESSMENT of athletes foot

Answer 51

DIAGNOSIS/ ASSESSMENT

The diagnosis of suspected fungal foot infection should be made on the basis of clinical features which allows classification into different sub-types. There may be a history of itchy, flaky, or painful skin of the feet.

Assessment of suspected fungal foot infection should include:

• Asking about the nature, site, and duration of symptoms; previous treatments; close contacts; co-morbidities.
• Examining the pattern, extent, and severity of infection, and for any associated inflammation or fungal infection at other sites.
• Arranging for skin sampling for fungal microscopy and culture if there is severe or extensive disease in adults, or the diagnosis is uncertain.

Question 52

Self-care advice for athletes foot

Answer 52

MANAGEMENT – SELF-CARE

• Wear well-fitting, non-occlusive footwear that keeps the feet cool and dry. Consider replacing old footwear which could be contaminated with fungal spores.
• Maintain good foot hygiene by wearing a different pair of shoes every 2–3 days.
• Wear cotton, absorbent socks.
• Avoid scratching affected skin, as this may spread infection to other sites.
• After washing the feet, dry thoroughly, especially between the toes.
• Do not share towels, and wash them frequently, to reduce the risk of transmission.
• Wear protective footwear when using communal bathing places, locker rooms, and gymnasiums, to reduce the risk of transmission.

Question 53

Medicine management of athletes foot

Answer 53

MANAGEMENT – MEDICINE

Advise treatment with a topical antifungal cream if there is mild, non-extensive disease in children and adults:

Options include terbinafine cream or an imidazole such as clotrimazole, miconazole, or econazole cream (available over-the-counter for specific age-groups). NHS Pharmacy first:

• Clotrimazole 1% and hydrocortisone 1% cream Pack Size 15g
  
  • Clotrimazole: Apply 2–3 times a day and continue for at least 4 weeks. A strip of cream about half a centimetre long is enough to treat an area about the size of the hand.
• Miconazole 2% and hydrocortisone 1% cream Pack Size 15g
  
  • Micronazole: see below
• Miconazole 2% cream Pack Size 15g
  
  • Apply twice a day for 2–6 weeks depending on the severity of the lesions, and continue for 10 days after all skin lesions are healed.
• Terbinafine 1% cream
  
  • >12Y only
  • Apply thinly to affected area once or twice a day for up to 7 days

Alternative options include over-the-counter undecenoic acid cream or topical preparations containing tolnaftate.

Consider prescribing a mildly-potent topical corticosteroid in addition, if there is associated marked inflammation, such as:

Hydrocortisone 1% cream to be applied once daily for a maximum of 7 days.

Advise that a topical corticosteroid preparation should not be used alone on skin lesions.

If severe oral anti-fungal treatment – GP.